Evidence Based Health Care

1
Evidence Based Health Care

• Dan Mayer MD
• Professor of Emergency Medicine
• Office of Medical Education
• Albany Medical College

2
Curricular change at Albany Medical College

• Systems themes
• Theme leaders
• Longitudinal courses
• HCS (Health, Care, and Society)
• LMI (LaGrange Medical Informatics)
• Nutrition
• Clinical Skills
• Initially called CCCS (Comprehensive Care Case
  Study), now called EBHC
• Teach to become life long learners
• Teach how the health care system works
• All are pass / fail

3
First year of the course 1993 - 4

• Lectures on biostatistics and epidemiology
• Articles from the current medical literature
• Course lacked
• relevancy
• well organized syllabus
• core group of interested preceptors
• Formation of theme group
• Lecture by NYS Health Commissioner
• Introduction of Power Reading

4
Basic mission of the course.

• What to teach our students to make them
  proficient in EBM? Where and how to do it!
• Skills for a life long learner
• Ability to frame a clinical question
• Informatics skills (searching the literature)
• Critical appraisal of the medical literature
• Biostatistics and clinical epidemiology
• Clinical decision making
• Preventive medicine
• Coordinate with basic science and clinical
  themes (courses and clinical clerkships).

5
Course overview

• 1st year
• Anatomy of the Health Care System
• Critical Appraisal of the Medical Literature
• 2nd year
• Medical Decision Making
• Evidence Based Medicine Exercise
• Cases
• 3rd and 4th year
• Clerkship specific EBM exercises

6
Educational process of first two
years

• Series of lectures transmit core material
• Small group Journal Clubs use Team Based
  Learning
• 22 students per group
• Physician or basic science faculty preceptor
• Present the clinical studies
• Discuss problems with the studies
• Decide how to use the study clinically
• Textbook Mayer D, Essential Evidence Based
  Medicine (Cambridge University Press, 2004)

7
Critical Appraisal of the Medical Literature -
Lectures

• Introduction to EBM, causation, anatomy of an
  article and study design
• Sources of bias (precision, accuracy,
  reliability, and validity)
• Type I errors (interpretation of results)
• Type II errors (interpretation of result
• Assessment of risk

8
1st year Journal Clubs

• Study design
• Sources of bias
• Type I and Type II errors (interpretation of
  results)
• Assessment of risk
• Randomized clinical trials
• Solving a real epidemic
• Medicine and the Media

9
Written work and presentations

• Papers of critical appraisal of studies
• Medicine and the Media paper (1st year)
• Alternative Medicine (2nd year)
• EBM Project (2nd year)
• Small group exercise (5-6 students and a clinical
  preceptor) to validate an algorithm or clinical
  guideline
• Case studies coordinate with themes
• Lymphohematopoietic (anemia)
• Cardiovascular (angina)
• Respiratory (pneumonia)
• Drug project and disease trajectory (3rd year)

10
Medical Decision Making- Lectures

• Introduction to medical decision making
  diagnostic reasoning
• Diagnostic test characteristics
• Likelihood ratios
• Sensitivity and specificity
• Predictive values
• Incremental gain / threshold values
• ROC curves
• Practice guidelines and studies of survival, cost
  effectiveness, and meta-analysis

11
2nd year Journal Clubs

• Problem set for diagnostic test characteristics
• Evaluation of screening tests (BRCA-1 PSA)
• Studies of diagnostic tests (White blood cell
  count for occult bacteremia)
• Survival analysis (Cardiovascular studies)
• Cost effectiveness (GI studies)
• Meta analysis (GI studies)

12
Third year

• Pediatrics - medical decision making exercise
• Medicine - Find answers to six clinical queries
  and create one CAT
• OB/GYN - risk management and medical legal
  exercise (lectures and presentation)
• Psychiatry - diagnostic tests in psychiatry
• Family Practice - evaluate medical Internet site
• Surgery - pain management (annotated bibliography
  and presentation)

13
Fourth year

• Acting Internship - use evidence based medicine
  to reduce cost of care
• Learning to Teach, Teaching to Learn - Evidence
  Based Medicine on rounds
• Neurology/Ophthalmology - risk management
  medical decision making exercise
• Emergency Medicine - EBM _at_ point of care
• Critical Care - survival analysis and rationing
  of care 'game'

14
Results of course.

• Quasi-experimental data from several sources
  suggest a beneficial effect of the course on
  improving knowledge and attitudes of medical
  students about EBM.
• National Board of Medical Examiners exam Step
  1
• Biostatistics and epidemiology subtests for 1999
  - 2002 were above the national average and the
  scores on all other subtests.

15
AAMC graduation surveySignificant differences
(plt0.05) in AMC student attitudes about EBM
compared to graduates of other US medical schools.

• Agree or strongly agree
• Statistics as pre-requisite for entry to medical
  school
• Excellent or good
• Teaching of biostatistics and epidemiology
• Adequate or excessive
• Time for EBM teaching
• Time for literature review critiquing
• Disagree or strongly disagree
• Expected to demonstrate EBM information in
  patient care
• See resident demonstrate use of EBM in patient
  care
• See attending demonstrate use of EBM in patient
  care.
• Were AMC students more able to recognize what is
  and is not actually evidence based care?

16

• Questions?